Validating the 4A's test in screening for delirium in a culturally diverse geriatric inpatient population

De, Jayita; Wand, Anne; Smerdely, Peter; Hunt, Glenn E.

doi:10.1002/gps.4615

Cited by 62 publications

(61 citation statements)

References 27 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Several validation studies have been published, showing supportive results, with satisfactory diagnostic accuracy (see Chapter 5). [55][56][57][58][59][60] An additional study also assessed the usability of the 4AT in the palliative care setting, finding positive results. 61 However, there is still a need for further diagnostic accuracy studies to inform clinicians about which tools to use in which contexts, especially given the large number of tools and validation studies of such tools available.…”

Section: The Need For a New Assessment Toolmentioning

confidence: 99%

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

MacLullich

Shenkin

Goodacre

et al. 2019

Health Technol Assess

View full text Add to dashboard Cite

Background Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 ‘A’s test (Arousal, Attention, Abbreviated Mental Test – 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. Methods Phase 1 – the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 – the 4AT’s diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. Results Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0–14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0–6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. Limitations Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. Conclusions These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. Future work Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. Trial registration Current Controlled Trials ISRCTN53388093. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.

show abstract

Section: The Need For a New Assessment Toolmentioning

confidence: 99%

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

MacLullich

Shenkin

Goodacre

et al. 2019

Health Technol Assess

View full text Add to dashboard Cite

show abstract

“…The measurement properties of the 4AT suit its application as a screening tool. It has good sensitivity (0.86) for detecting cognitive impairment in stroke patients and for detecting possible delirium (sensitivity 0.86‐1.00 and specificity 0.69‐0.84) . Similar test properties for delirium detection were reported with RNs using the 4AT in an Australian geriatric inpatient population (sensitivity 0.87 and specificity 0.80), and importantly, the sensitivity (0.91) was good in CALD patients .…”

Section: Methodsmentioning

confidence: 69%

“…It has good sensitivity (0.86) for detecting cognitive impairment in stroke patients and for detecting possible delirium (sensitivity 0.86‐1.00 and specificity 0.69‐0.84) . Similar test properties for delirium detection were reported with RNs using the 4AT in an Australian geriatric inpatient population (sensitivity 0.87 and specificity 0.80), and importantly, the sensitivity (0.91) was good in CALD patients . The 4AT (version 1.2) was selected as the screening tool because it is validated to detect both cognitive impairment and delirium, can be used by a variety of clinicians, is applicable to a range of populations and is brief.…”

Section: Methodsmentioning

confidence: 87%

Evaluation of a method to estimate the point prevalence of cognitive impairment and delirium in a multi‐campus Australian health service

et al. 2019

View full text Add to dashboard Cite

Objective To design, test (pilot) and implement a study to estimate the point prevalence of cognitive impairment (CI) and delirium in a multi‐site health service. Methods Clinicians were trained to use the 4 A's Test (4AT) to screen for cognitive impairment and delirium, and the 3‐minute Diagnostic Interview for the Confusion Assessment Method (3D‐CAM) to detect delirium in those with abnormal 4AT results. Outcomes of interest were as follows: (a) rates of cognitive impairment and delirium and (b) feasibility of the approach measured by participation rate, “direct survey activity” time, cost and surveyor preparation. Results The rates of cognitive impairment and delirium were 43.8% (245/559) and 16.3% (91/559), respectively. 90.5% (563/622) of eligible adult patients from 25 acute and subacute wards were seen. “Direct survey activities” averaged 14 minutes (range 2‐45) and cost $11.48 per patient. Training evaluation indicated additional education in the 4AT and 3D‐CAM was needed. Conclusion Health services could use this streamlined, inexpensive method to estimate the point prevalence of cognitive impairment and delirium.

show abstract

“…Both can be diagnosed and quantified using simple scoring systems (e.g. 4AT ), which should be incorporated into institutional multicomponent intervention pathways (Appendix 2 ). Using awareness‐raising factsheets, carers and relatives can be helped to identify early, subtle changes in cognition that might herald delirium.…”

Section: Postoperative Carementioning

confidence: 99%

Guidelines for the peri‐operative care of people with dementia

et al. 2019

View full text Add to dashboard Cite

Ageing populations have greater incidences of dementia. People with dementia present for emergency and, increasingly, elective surgery, but are poorly served by the lack of available guidance on their peri-operative management, particularly relating to pharmacological, medico-legal, environmental and attitudinal considerations. These guidelines seek to deliver such guidance, by providing information for peri-operative care providers about dementia pathophysiology, specific difficulties anaesthetising patients with dementia, medication interactions, organisational and medico-legal factors, pre-, intra-and postoperative care considerations, training, sources of further information and care quality improvement tools.

show abstract

Validating the 4A's test in screening for delirium in a culturally diverse geriatric inpatient population

Abstract: The 4AT is a sensitive and specific screening tool for delirium in geriatric inpatients, including those with probable dementia or who are non-English speaking. Copyright © 2016 John Wiley & Sons, Ltd.

Cited by 62 publications

References 27 publications

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

Evaluation of a method to estimate the point prevalence of cognitive impairment and delirium in a multi‐campus Australian health service

Guidelines for the peri‐operative care of people with dementia

Contact Info

Product

Resources

About